MEDICARE: KELAN G. TANTISIRA MD MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RP1001X	Pulmonary Disease Physician	155411	MA
2	208000000X	Pediatrics Physician	G67143	CA
3	207RP1001X	Pulmonary Disease Physician	G67143	CA

General Provider Information

NPI Number	:	1760420434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELAN G. TANTISIRA MD MPH

Provider Business Mailing Address
First Line	:	3020 CHILDRENS WAY # MC5003
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4223
Country	:	US
Telephone Number	:	858-309-6300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 CHILDRENS WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4232
Country	:	US
Telephone Number	:	858-966-5846
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	01/07/2021

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